| NPI | 1841245750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA972) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 01162) |
| Enumeration Date | 2006-05-23 |
| Last Update Date | 2021-09-22 |